Speech by AMA President, Dr Bill Glasson to the Financial Review 6th Annual Health Congress 2004 - The Future for Australia's Healthcare Sector: The Practitioner's Perspective - Health System Priorities. 'Dr Jones or Dow Jones??' Rydges Jamison, Sydney

24 Feb 2004

** Check against delivery

 

Good morning ladies and gentlemen.

Today you will hear lots of numbers and anecdotes and accusations and predictions and promises about Australia's health system.

With a star-studded line-up of politicians this morning, you will have already heard a fair variety of opinions and a lot of blame-shifting - across Party lines and across Commonwealth-State lines.

We hear through the media there are lots of things going wrong in the health system.

An operation gone bad.

Sick kids in search of a doctor.

Bed shortages.

Ambulances doing 360s around city streets in search of a hospital to take their patients.

But that's not always the case.  In fact, there's a lot to like about our health system.

Sadly the good bits don't make the front pages all that often.  And that's a great pity.

I have been asked to present a medical practitioner's perspective on health.  That's a very tough ask.

Every GP, every specialist, every doctor-in-training and every student doctor has a different story to tell.

They are stories from the coalface of medicine.  They are based on experience of the system and patient care.

There have been many changes in the medico-political landscape - some good, some bad - since my predecessor, Dr Phelps, spoke to you last year.

Medical indemnity and Medicare are the most notable.

The indemnity situation is looking brighter...and Tony Abbott has played a major role in accelerating much-needed reform in this area.

There is still more to do, however.

The Medicare policy debate continues at a rate of knots.

Both Tony Abbott and Julia Gillard will have lots more to say about Medicare before the election.

It is fitting that I follow both Tony and Julia on the speaking list this morning...because I'll be following them everywhere this year.

Every promise.  Every utterance.  I'll be there to pass judgement and offer suggestions and advice on behalf of the doctors and patients of Australia.

Right up to election day.

I'll keep reminding them that bulk billing is not the principal measure of the success or failure of the health system.

For patients, the key is being able to see a doctor when you need one.

But that is a message that both sides are reluctant to heed.

It's fitting also to have the States here today.  Both NSW Premier Bob Carr and Victoria's Bronwyn Pike know the sensitivity of health policy.

Especially when the lines between Commonwealth and State responsibility are so hazy and confused in the public mind...and in the media.

A front page shellacking in the tabloids over health is not a good look for any Government.

The problem for governments is that the Australian public is more cluey about health policy than ever before.  They demand and deserve results.

Equity - Access and Affordability

Australia is an egalitarian society but we are clearly not providing an egalitarian health system.

You can still get easier access to health care based on your income or where you live - and that is a major challenge facing health policy in this country today.

The mention of Premier and car just now - with apologies to Bob Carr - provides a neat analogy of what our system should be like.

Holden used to make a car called the Premier.  It was a little bit up-market.

They also used to make the Statesman.  Very flash.

But there was also the Kingswood - the car of the masses - and its lesser partner - the Belmont.  More recently the Commodore.

For younger drivers there was the Monaro or the Torana.

Older members of our community look back fondly on the EH or the FJ.

They may even still have one in the garage.

And country folk could always get hold of a ute when they needed one.

The point I'm making is that no matter what your socio-economic profile - rich or poor, young or old, fast or slow - there was a car for you.  And it was affordable.

Everybody had access.  Everybody had choices.

It's not as easy to get hold of a doctor when you need one these days, especially in country or outer-suburban areas.

The concept of universal access to health care has eroded.

Many Australians are paying more for their health care because Medicare has been neglected.

But it doesn't have to be that way.

If we can find money for border protection and offshore detention centres, we can properly fund our health system.

We must support our public hospitals, keep our GPs in the system, maintain and improve our public health services, promote indigenous health, and look after the health of our kids.

We should be training enough doctors and nurses to serve the population wherever they live, no matter how small or remote their community.

But it is not just a matter of training the right number of doctors.  We must find ways to get them to the communities without doctors, and keep them there.  But it must be their choice.

Health policy should always be about people and communities.  Health policy should be visionary.

This is a Financial Review Conference - and many of you are economists - but we must not allow the health of Australians to become another commodity to trade on the stock exchange.

Human health should not be left to market forces to the extent that it is in the United States.

The health of Australians must be based more on Dr Jones, not the Dow Jones.

It's all about access and affordability, not bulls and bears.

People must be the priority, not economics.

We have heaps of unmet health need and not enough doctors.

We have a nine-to-five funding mentality, but we have patients who through no fault of their own get sick after hours.

We have a Medicare Benefits Schedule based on 1970s costings.

But the patients are suffering from 21st century ailments that need expensive 21st century treatment and care.

We have a hospital and aged care facility network that may have worked for a younger 1980s population profile.

But we are getting older.

The aged care network is groaning under the pressure of a rapidly ageing and more demanding population.

Health, like any political or social issue, divides the community.

The Health System - Where We're At

Some say that the health system is in crisis.

They say it can only get worse as the cost burden of our ageing population bears down on government and household budgets.

Doomsayers quote Hanrahan—"we'll all be rooned".  And there may be some truth in elements of these arguments.

Others point to statistics - good old statistics - that indicate Australia has an excellent health system by world standards.

But try telling that to accident and emergency staff in any capital city on a Saturday night.

The stats show that we may have:

  • very good health outcomes
  • reasonable access overall
  • increasing life expectancy
  • an improving quality of life
  • low rates of medical misadventure
  • and a highly skilled and hard working health workforce.

And we deliver a large number of health services - 220 million medical services and 6 million hospital admissions per year.

But for every good stat, there is a bad stat.

And the bad outcomes - the few - get more publicity than the good outcomes - the vast majority.

As a doctor, my focus and the AMA's focus is to eliminate the negative outcomes and the negative perceptions wherever possible.

We can and must raise the standards of care and health outcomes across the board and we can and must fill in the potholes - meet the unmet need.

I think the evidence is clear that the health priority from all Governments...at least funding-wise...is not high enough.

And the patients - the voters - know that.

I can tell you that the doctors know it.

I work in both the public and private systems.

I work in both the country and the city.

I meet doctors and patients from all walks of life and from all parts of this great country and I know what they think of the health system.

They know more than the bureaucrats and the politicians.

I get paid well as a specialist but I also perform pro bono work both here and overseas.

Many doctors do the same.

Politicians and journalists and economists and some so-called health experts like to portray doctors as part of the problem.

'Greedy doctors', they say.

That's the easy way out of a problem - the gutless way.  And it's a nonsense.  It defies reality.

If doctors are doing so well, why do we have a national medical workforce shortage like never before in this country?

Why are so many doctors leaving the system, taking early retirement or opting to work part-time?

We became doctors out of a genuine desire to help people.  It is a wonderful job. 
A God-given job.

Medicine has traditionally been the top of the heap of career choice for our best and brightest students.

That reputation is slipping away.

Why?

Too many bloody hurdles.  Too much intervention.

The doctor-patient relationship does not want or need a Treasury official as note-taker.

The doctor-patient relationship does not need the ACCC to brand rosters and job-sharing as anti-competitive.

Student doctors should not be press-ganged into serving in country areas.

A doctor should practice where he or she wants to practice, but incentives are needed to attract them to work in more remote areas.

Red tape is strangling general practice.

The Medicare patient rebate is dudding the patient.

These are causing massive damage to the system.

Labelling health as a cost burden is completely wrong-headed.

Health is an investment—an investment in a healthy and productive society.

The rates of return—the lifespan gained from good quality interventions of both a curative and preventative nature—can be quite spectacular.

To illustrate this point, as an ophthalmologist I can say from experience how a cataract operation can affect a person's life.

A successful operation can dramatically improve the quality of life for the patient.

On the other hand, no operation can mean daily sight dysfunction and possible blindness for life.

And that is a costly outcome both for the patient and for the community at large.

The patient becomes highly dependent on carers.

But why go down this path when the operation itself is relatively inexpensive and very safe.

Overnight hospital stays are now the exception.  The patient can be in and out on the same day in a matter of hours.

The benefits are obvious and profound.

People can see to drive, to cook, to read a newspaper and to watch television.

They can get on with their lives.

It's foolish to fret over the costs while ignoring the benefits.

Medical Workforce

Earlier I alluded to Australia's medical workforce shortage.

This shortage is greatest in general practice - the gateway to primary health care - the first stop for most Australians outside accident and emergency.

It's time to debate the explicit adoption of some objectives for access to primary care, and they need to be realistic objectives.

One such example is a 48-hour rule.

That is, people should be able to get access to a GP within 48 hours.

If that can't be met, the system should be responding to restore access to an acceptable level.

There is no point in patients expecting governments to adopt a 5-minute rule, because the community wouldn't be prepared to pay for it.

There is much we can do to address the immediate issues around GP shortages.

We can reconsider incentives to keep older GPs in the workforce.

We can rethink the incentives to get GPs into areas of need.

The profession itself can rethink the way it involves other health professionals in delivering high quality primary care - practice nurses, for example.

There is unrealised potential for practice nurses teamed with GPs to improve access to good quality primary health care.

Patient Expectations

And patient expectations also have to change.

Our ageing population is just one significant story of how patient expectations are changing.

On the surface, it is a story of the rise and rise of chronic illness.

There are many successes with the treatment of cardiovascular disease and cancer, to name two.

But more people have chronic illnesses such as arthritis, diabetes and dementia.

It is inevitable that resources will have to move to those areas.

The health system must respond to the needs of the ageing population.

As things stand, we cannot cure arthritis, we cannot cure diabetes and we cannot cure dementia.

But there's quite a lot that can be done to manage those diseases, and to help patients improve their self-management.

What we pay for, and where we put the services, does matter.

Patients also have a responsibility.

Changes in lifestyle now can mean fewer problems with health later in life.

As a community, we have not yet won the war on smoking.

We are losing the war on obesity...but we have a better battle plan than ever before.

Australians are losing the sense of urgency about immunisation.

This casual attitude is allowing the return of diseases we thought had been banished from our lives.

We have to turn these things around if we are to have a healthier population.

The PBS

One sure step to better health is proper use and management of the Pharmaceutical Benefits Scheme - the PBS.

This is the Scheme the Americans wanted to have greater influence over in the latest trade talks.

Hands off our PBS!!

The PBS may be the fastest growing program in the health Budget, but that's no reason to slash it.

A bit of simple economic forecasting will show that the growth in the PBS may be the very thing that keeps overall health within reasonable limits in the longer term.

We expect that new pharmaceutical treatments will be very important in delivering the higher quality but still moderate cost health system that Australians deserve.

Blocking access to new drugs may increase both the direct costs of health care and the indirect costs of poor health.

The two-tiered PBS co-payments structure is crude.

It delivers high subsidies to some in the community with very substantial assets, while it creates poverty traps for others.

Co-payments can block access, especially if the safety net arrangements are underdone.

With the PBS, there is always a case for protecting the sickest in the community from a crippling financial burden.

A smart Government or Opposition would look at a combined PBS/MBS safety net to help the disadvantaged.

Politicians, doctors, health economists and bureaucrats just love talking about the innards of health.

The public, on the other hand, subscribes to the Joe Friday maxim: "Just the facts, ma'am".

And the facts are just about always related to our public hospitals.

Public Hospitals

Our public hospitals should be national treasures, not national scandals.

At the political level, the public hospital debate is always about money and who's to blame.

It's undeniable that public hospitals are currently struggling to cope.

In the next couple of years, it will become self-evident that 5% growth in nominal funding for public hospitals is simply not enough to keep the system safe and functional.

The sooner the Federal and State Governments come back to the table to renegotiate a more realistic funding formula, the better.

Private Health Rebate

Another big question facing our politicians this election year is the 30 per cent private health rebate and lifetime health cover.

The Government is committed to them.

The Opposition says it's committed to them...sort of.

The minor parties hate them.

The independents are, well.......independent.

The AMA supports the initiatives.  They work.  They maintain the much-needed balance between the public and private systems.

I noted with interest an article last week in the Fin Review by Ian Harper and Chris Murphy who predict that the private health membership is sustainable at current levels until at least 2041-42.

This is a long-range forecast.  A lot can change in forty years.

Medibank Private commissioned the research.

The AMA has often suggested that greater efficiency, better products, and lower management costs in the private health insurance sector may help ease the burden on the taxpayer.

Not surprisingly, the industry continues to blame the doctors for any cost blow-outs.

At the moment, the arguments for the rebate are strong.

Between 1996-97 and 2001-02, private hospital separations grew by 44%.

Public hospital separations grew by 9%, down from more than 23% in the preceding five years.

It is widely held that the 30% rebate and Lifetime Health Cover together brought substantial relief to public hospitals.

The arrangements have taken stress off Federal and State budgets because the private financing option engages a patient contribution that is not available under Medicare.

The private health insurance rebate will no doubt continue to feature on the agenda of Australian Health Care Agreement meetings...as it will in the coming election campaign.

Australian Health Care Agreements

It is a great disappointment that so much work goes into these meetings but so little - for the long-term - comes out.

Short-term political goals tend to outweigh long-term community health needs.

The good ideas generated in the reform agenda should be grasped, not consigned to the dustbin.

And there are good ideas out there, such as:

  • specialisation of urban hospitals, to avoid the wastage of duplicating costly services, equipment and personnel a few kilometres apart.
  • improving primary care outcomes for patients.
  • reducing the number of hospital admissions, especially among Indigenous Australians, that could have been avoided with more appropriate primary care or intermediate step-up care.
  • addressing the shortage of GPs which is adding, inappropriately, to the workload pressures on the public hospitals.

I'd like to add here that I would like to see a more cooperative approach to health policy and financing.

Health funding must be a permanent agenda item for COAG - to be discussed by Prime Ministers and Premiers, not just the Health Ministers.

I will speak more about this at another time, but I flag today my support for a 'Collaborative Federalism' approach to health financing.

Aged Care

Aged care is a big issue...and an expensive one when it comes to government funding.

The demand for aged care services is rapidly growing as the population in the over-65 age group is escalating.

In 1998, there were 2.3 million Australians aged over 65 years.

There will be 4 million in 2021, and 5.7 million in 2041 (Professor Len Gray.  Two Year Review of Aged Care Reforms, Canberra 2001).

By 2021, between 1.3% and 2.1% of the population will be over 85.

These are old figures.

Aged care is fundamentally a health care issue.

Better integration of services for older people must be sought through a cooperative, multidisciplinary approach.

This must involve GPs, geriatricians, other medical specialists, nurses, and allied health professionals.

And it must cover wherever older people are living and receiving care: in the community, in aged care homes, and in hospital.

The AMA is determined to ensure aged care is a key public policy issue in this federal election year.

One specific issue that needs attention is the epidemic of dementia.

Dementia is now clearly burdening many of our older people - and their families - and the aged care and health services that must deal with it.

A report last year by Alzheimer's Australia projected that well over half a million Australians will have dementia by mid-century.

That is a frightening and daunting 2.3 % of the population.

This compares to the 2002 figures of 162,000 Australians, or just 0.8% of the population, with diagnosed dementia.

To come to grips with this epidemic, the AMA supports calls for dementia to be identified as a National Health Priority

Substantial funding for research and treatment of dementia is needed.

As my time is running out, I'll quickly touch on some other items that colour the practitioner's perspective of health.

National Pharmaceutical Program

A national pharmaceutical program should be achievable.

We cannot tolerate anything less.

It's on the health reform agenda - the NGO agenda at least - and we must make sure it stays on the Government's agenda.

It costs no more and the benefits are substantial. In fact it could deliver substantial savings over time.

Shifting Private Health Money To The Public Sector

We must look at ways to more efficiently shift more money into the public system from private health insurance.

Private health insurers pay public hospitals a regulated bed day benefit when they treat private patients.

It has been allowed to erode over the years and no longer provides an incentive for public hospitals to admit private patients.

If the bed day benefit were increased to more realistic levels, a spin off would be that public hospitals would see a greater value in the private health insurance rebate.

Medical Training

The profession's commitment to high quality training, and continuing training of GPs must be maintained.

Again I urge the Government to scrap its unfunded bonded medical places.

They won't work.

They will backfire.

They will make the workforce situation worse.

And please keep the ACCC away from the medical colleges. 

Bureaucratic meddling in the name of 'competition policy' will rob the community of talented specialists.

As I said before, do not treat medical practice in Australia as you would a listed company.

The Australian people see health as a community service, not big business.

Conclusion

Recent events have shown that politicians and doctors can work together to deliver better outcomes for patients.

The Government's medical indemnity package has put security and certainty back into the system for many.

Not everyone yet, but we're still working on solutions.  There is no 'one size fits all' solution with medical indemnity.

The AMA will work with the Government to plug the gaps in the package.

With Medicare, I have witnessed unprecedented willingness from all parties to discuss the issues with the medical profession, especially through the AMA.

This is a good sign for health policy.

Health is a big-ticket item for Government.  Many billions of dollars must be spent.

Is health funding enough?  Probably not.  And probably never will be.  But we have to extract every dollar we can.

Is it well directed?  Probably not.

Is the patient getting the best possible care?  The evidence - particularly the media coverage - says no.

Are doctors happy?  The exodus from the profession suggests not.

But underneath it all is a very good health system yearning to be nurtured.

Election years are good nurturing years.

In the meantime, we must all look upon our health system - the health of all Australians - now and into the future - as a social issue, not a business issue.

Doctors deliver babies, not profits.

We're more interested in sutures than futures.

And our patients are not All Ordinaries.  They're all special.

Thank you.

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